Color Atlas of Emergency Trauma

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Color Atlas of Emergency Trauma

sec o n d ed i t i o n


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COLOR ATLAS OF

EMERGENCY TRAUMASECOND EDITION

Edited by

Demetrios Demetriades, MD, PhD, FACSProfessor of Surgery, University of Southern Californias Keck School of Medicine, and

Vice-Chairman of Surgery and Director of the Trauma Program and Surgical Intensive

Care Unit at the Los Angeles CountyUSC Medical Center

Edward J. Newton, MD, FACEP, FRCPCProfessor and Chairman of Emergency Medicine, University of Southern Californias

Keck School of Medicine, and Chairman of the Los Angeles CountyUSC Medical

Centers Department of Emergency Medicine


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ca mbri d g e u n i v e rsi ty p re ss

Cambridge, New York, Melbourne, Madrid, Cape Town,

Singapore, Sao Paulo, Delhi, Tokyo, Mexico City

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org

Information on this title:www.cambridge.org/9781107001527

# Demetrios Demetriades and Edward J. Newton 2011

This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,

no reproduction of any part may take place without

the written permission of Cambridge University Press.

First published 2011

Printed in the United Kingdom at the University Press, Cambridge

A catalogue record for this publication is available from the British Library

Library of Congress Cataloging-in-Publication Data

Demetriades, Demetrios, 1951

Color atlas of emergency trauma / Demetrios Demetriades, Edward J. Newton. 2nd ed.

p. cm.

Rev. ed. of: Color atlas of emergency trauma / Diku P. Mandavia, Edward J. Newton, Demetrios Demetriades. 2003.

Includes bibliographical references and index.

ISBN 978-1-107-00152-7 (Hardback)

1. Medical emergenciesAtlases. 2. Emergency medical servicesAtlases. 3. Wounds and injuriesAtlases. I. Newton, Edward,

1950 II. Mandavia, Diku P., 1965 Color atlas of emergency trauma. III. Title.

[DNLM: 1. Wounds and InjuriesAtlases. 2. EmergenciesAtlases. WO 517]

RC86.7.M3478 2011

616.020

50222dc22 2011013009

ISBN 978-1-107-00152-7 Hardback

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites

referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

All material contained within the CD-ROM is protected by copyright and other intellectual property laws. The customer acquires only t

right to use the CD-ROM and does not acquire any other rights, express or implied, unless these are stated explicitly in a separate licenc

Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted

standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to

disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the

information contained herein is totally free from error, not least because clinical standards are constantly changing through research an

regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use

material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of andrugs or equipment that they plan to use.
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Dedicated with thanks to my family and colleagues. To my students of

trauma and emergency care, may the collected experience contained in

this atlas assist your pursuit of excellence.

E. Newton

To my parents, my wife Elizabeth, my daughters Alexis and Stefanie,

and my son Nicky.

D. Demetriades


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Contents

List of contributors x

Foreword by David B. Hoyt and Sandra M. Schneider xi

Preface xiii

Acknowledgments xiv

1 HEAD INJURY 1Demetrios Demetriades and Leslie

Kobayashi

1.1 Scalp Injuries 4

1.2 Skull Fractures 4

1.3 Intracranial Hematomas 11

1.4 Penetrating Head Injury 20

1.5 Transtentorial Herniation 24

1.6 Diffuse Cerebral Edema 26

1.7 Pediatric Head Injury 27

1.8 Diffuse Axonal Injury 28

2 FACIAL INJURY 30Edward J. Newton

2.1 Eye Injuries 33

2.2 Periorbital Lacerations 37

2.3 Facial Fractures 37

2.4 Nasal Injuries 42

2.5 Penetrating Facial Trauma 42

2.6 Complex Oromaxillofacial

Trauma 442.7 Facial Nerve Injury 47

2.8 Parotid Gland Injury 48

3 NECK INJURY 50Demetrios Demetriades and Lydia Lam

Penetrating Neck Injuries 52

3.1 Anatomical Zones of the Neck 52

3.2 Epidemiology of Penetrating Neck

Trauma 54

3.3 Physical Examination of Penetrating Injuri

of the Neck 54

3.4 Protocol for Initial Evaluation and

Management of Penetrating Injuries to the

Neck 56

3.5 Radiological Investigations for PenetratingNeck Trauma 57

3.6 Evaluation of the Vascular Structures in th

Neck 59

3.7 Evaluation of the Aerodigestive Tract in th

Neck 63

3.8 Airway Establishment in the Presence of a

Neck Hematoma 65

3.9 Bleeding Control in the Emergency

Department 66

3.10 Penetrating Trauma to the Carotid

Artery 683.11 Penetrating Trauma to the Vertebral

Artery 69


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3.12 Penetrating Trauma to the Subclavian

Vessels 70

Blunt Neck Trauma 71

3.13 Vascular Injuries 72

3.14 Blunt Laryngotracheal Trauma 74

4 THORACIC INJURY 75Demetrios Demetriades and Peep Talving

4.1 Chest Wall, Soft Tissues 78

4.2 Rib Fractures 78

4.3 Hemo-Pneumothorax 81

4.4 Lung Contusion 89

4.5 Subcutaneous Emphysema 90

4.6 Penetrating Cardiac Injury 92

4.7 Blunt Cardiac Trauma 100

4.8 Blunt Thoracic Aortic Injury 101

4.9 Penetrating Thoracic Outlet Injuries 105

4.10 Transmediastinal Gunshot Wounds 1074.11 Diaphragmatic Injuries 109

4.12 Esophageal Injuries 114

4.13 Thoracic Duct Injury 116

4.14 Traumatic Asphyxia 117

4.15 Impaled Thoracic Foreign Bodies 118

5 ABDOMINAL INJURY 119Demetrios Demetriades and Kenji Inaba

Blunt Abdominal Trauma 1225.1 Mechanism of Injury 122

5.2 Diagnosis of Hemoperitoneum 123

5.3 Splenic Injuries 125

5.4 Liver Injuries 127

5.5 Pancreatic Injuries 131

5.6 Renal Injuries 133

5.7 Bladder Injuries 135

5.8 Urethral Injuries 137

5.9 Duodenal Injuries 139

5.10 Small-Bowel Injuries 140

5.11 Colorectal Injuries 141Penetrating Abdominal Trauma 142

5.12 Mechanism of Injury 142

5.13 Investigations in Penetrating Abdominal

Injury 144

5.14 Transpelvic Gunshot Injuries 145

5.15 Penetrating Injuries to the Liver 146

5.16 Penetrating Splenic Injuries 149

5.17 Penetrating Pancreatic Injuries 150

5.18 Penetrating Renal Injuries 150

5.19 Penetrating Colorectal Injuries 152

5.20 Abdominal Vascular Injuries 153

5.21 Abdominal Trauma in Pregnancy 154

6 MUSCULOSKELETAL INJURY 16Edward J. Newton

6.1 Classification of Fractures 161

6.2 Open Fractures 162

6.3 Mangled Extremity 163

6.4 Open Joint Injury 164

6.5 Epiphyseal Injuries 165

6.6 Torus and Greenstick Fractures 166

6.7 Supracondylar Fracture 167

6.8 Amputations 168

6.9 Tendon Injury 1706.10 Peripheral Vascular Injury 170

6.11 Peripheral Nerve Injury 174

6.12 Metacarpal Fractures 177

6.13 Scaphoid Fractures 178

6.14 Scapholunate Dislocation 179

6.15 Lunate and Perilunate Dislocation 179

6.16 Wrist Fractures 180

6.17 Forearm Fractures 181

6.18 Elbow Dislocation 183

6.19 Radial Head Fracture 183

6.20 Humeral Fracture 1846.21 Shoulder Dislocation 185

6.22 Clavicle Fracture 187

6.23 Sternoclavicular Dislocation 188

6.24 Scapula Fracture 188

6.25 Pelvic Fractures 189

6.26 Hip Dislocation 193

6.27 Hip Fractures 195

6.28 Femoral Shaft Fracture 196

6.29 Patellar Fracture 197

6.30 Tibial Plateau Fracture 198

6.31 Knee Dislocation 1986.32 Maisonneuve Fracture Complex 200

6.33 Ankle Dislocation 201

6.34 Subtalar Dislocation 202

6.35 Lisfranc Fracture 203

6.36 Metatarsal Base Fractures 204

6.37 Calcaneal Fractures 205

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7 SPINAL INJURIES 207Mark J. Spoonamore and Demetrios

Demetriades

Spinal Cord Injuries 211

7.1 Complete Spinal Cord Transection 211

7.2 Central Cord Syndrome 213

7.3 Brown-Sequard Syndrome 215

7.4 Anterior Cord Syndrome 216

Upper Cervical Spine Dislocations 216

7.5 Atlanto-Occipital Dislocation 217

7.6 Atlantoaxial Dislocation 218

7.7 Rotatory Subluxation of C-1 on C-2 219

7.8 Ligamentous Injuries 220

Cervical Spine Fractures 222

7.9 C-1 Burst Fracture (Jefferson Fracture) 222

7.10 Odontoid (Dens) Fractures (C-2) 224

7.11 Hangmans Fracture (C-2) 226

7.12 Fractures of the Lower Cervical Spine(C-3C-7) 228

7.13 Flexion and Extension Teardrop Fracture 229

7.14 Compression or Burst Fracture of the

Vertebral Body 231

7.15 Clay Shovelers Fracture 232

7.16 Fractures of the Pedicles, Laminae, and

Lateral Masses 233

7.17 Facet Dislocation 234

7.18 Cervicothoracic Spinal Injury 237

Thoracic Spine Injuries 239

Lumbar Spine Injuries 2427.19 Lumbar Compression Burst Fractures 242

7.20 Chance Fractures 245

7.21 Fracture-Dislocation of the Lumbar Spine 247

Pediatric Spinal Injury 248

Penetrating Injuries to the Spinal Cord 250

8 BURN INJURIES 253Andrew Tang, Charity Wip, Warren Garner,

and Demetrios Demetriades

Extent of Burn Injury 256

8.1 First-Degree Burn 256

8.2 Second-Degree Burn 257

8.3 Third-Degree Burn 261

8.4 Fourth-Degree Burn 262

Special Considerations of Burn Injury 26

8.5 Inhalation Injury 263

8.6 Abdominal Compartment Syndrome 264

8.7 Circumferential Burn 265

8.8 Scald Burns 266

8.9 Chemical Burns 267

8.10 Electrical Burns 268

8.11 Outcome of Burn Injury 269

9 SOFT TISSUE INJURIES 271Demetrios Demetriades and Marko Bukur

9.1 Dog Bite Injury 273

9.2 Cat Bite Injury 275

9.3 Human Bite Injury 276

9.4 High-Pressure Injection Injury 278

9.5 Retained Foreign Body 279

9.6 Extremity Compartment Syndrome 280

10 BALLISTICS 284Ramon Cestero, David Plurad, and Demetrios

Demetriades

10.1 Definitions 284

10.2 Low-Velocity Projectiles 286

10.3 High-Velocity Projectiles 288

10.4 Shotgun Injuries 291

10.5 Blast Injuries 29510.6 Nonlethal Weapons 299

10.7 Myths and Facts about Bullets 300

11 DISASTER MEDICINE 301Edward J. Newton

11.1 Epidemiology of Injuries in Mass

Disasters 301

11.2 Triage 302

11.3 Specific Injuries 30411.4 Guidelines for Rescue Efforts 306

Index 308

Contents


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Contributors

Marko Bukur, MDFellow in Trauma and Surgical Critical Care,University of Southern Californias Keck School ofMedicine, CA, USA

Ramon Cestero, MDFellow in Trauma and Surgical Critical Care,

University of Southern Californias Keck School ofMedicine, CA, USA

Demetrios Demetriades, MD, PhD, FACSProfessor of Surgery, University of SouthernCalifornias Keck School of Medicine andVice-Chairman of Surgery and Director of the TraumaProgram and Surgical Intensive Care Unit at theLos Angeles CountyUSC Medical Center, CA, USA

Warren Garner, MDProfessor of Surgery, University of Southern

Californias Keck School of Medicine, CA, USA

David B. Hoyt, MD, FACSExecutive Director, American College of Surgeons

Kenji Inaba, MD, FRCSC, PhD, FACSProgram Director, Surgical Critical Care Fellowship,University of Southern Californias Keck School ofMedicine, CA, USA

Leslie Kobayashi, MDFellow in Trauma and Surgical Critical Care,

University of Southern Californias Keck School ofMedicine, CA, USA

Lydia Lam, MDAssistant Professor of Surgery, University of SouthernCalifornias Keck School of Medicine, CA, USA

Edward J. Newton, MD, FACEP, FRCPCProfessor and Chairman of Emergency Medicine,University of Southern Californias KeckSchool of Medicine and Chairman of theLos Angeles CountyUSC MedicalCenters Department of Emergency Medicine,CA, USA

David Plurad, MDCommander in the US Navy; Director,US Navy Trauma Training Center,

Los Angeles CountyUSC Medical Center,CA, USA

Sandra M. Schneider, MDPresident, American College of EmergencyPhysicians

Mark J. Spoonamore, MD

Assistant Professor, Clinical OrthopedicSurgery; Medical Director, Center for Spinal SurgeUniversity of Southern Californias Keck School Medicine, CA, USA

Peep Talving, MD, PhD, FACSAssistant Professor of Surgery, University ofSouthern Californias Keck School of Medicine,CA, USA

Andrew Tang, MDSurgical Critical Care Fellow, University

of Southern Californias Keck School of MedicinCA, USA

Charity Wip, MDBurn Unit Fellow, Los Angeles CountyUSC TraumCenter, CA, USA

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Foreword

The second edition of theColor Atlas of Emergency Traumais a definitive addition to thpublished works on traumatic injuries. The first edition received critical acclaim from tinternational trauma community, including a commendation from the British MedicAssociation. The new edition is more vivid, with more figures and illustrations, and wundoubtedly receive similar praise.

What sets this wonderful text apart from others of its type is the selection of criticimages that vibrantly illustrate the steps involved in determining the presence of

injury. The authors have combined succinct text with graphic images, which will helearners retain a visual picture of the relevant details they will need to remember whe

they encounter injuries in their practices. Each chapter includes an introduction adescription of epidemiology, clinical findings, and investigations, all of which are compl

mented by numerous photographs highlighting the injuries and making each scenario anproblem feel real.

The experience this book offers is a great adjunct to traditional texts and to otheducational resources. It is visual. It is relevant. It gets right to the point, and it maklearning complex concepts much easier and exciting.

The authors are amongst the most experienced trauma surgeons in the nation. Thhave written on virtually every topic in clinical trauma and have led our thinking in moaspects of trauma care for more than 20 years. Dr. Demetriades eye towards importa

details of each diagnosis is reflected in the photographs and diagnostic images choseThe reader will enjoy learning about the spectrum of traumatic injuries by using this atlThe student learning trauma from a traditional textbook, when complemented by thColor Atlas of Emergency Trauma, will have a facilitated learning experience. This booshould be standard reading for any trauma surgeon or student.

David B. Hoyt, MD, FAC

Executive Director, American College of Surgeo

Trauma is pervasive in our society and as much as any area of medicine, it requires raprecognition and intervention to preserve life. Trauma care also requires a coordinated an

cooperative approach by multiple specialists for optimal outcome. This text is an exampof that cooperation. The systematic presentation of physical, radiographic and operatifindings makes this a valuable resource for clinicians, teachers, and students.

Sandra M. Schneider, M

President, American College of Emergency Physicia


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Preface

Trauma is very different from other emergency medical conditions. Very often there is clinical history available and the treatment is given before the definitive diagnosis. Thphysiological reserves of many trauma victims are limited and small errors can carryheavy price. The comprehension and intuition required to treat traumatic injury is gainover many years of clinical experience at the bedside of critically injured patients. Thaim of this atlas is to share the experience of the authors from one of the largest traumcenters in the United States and provide a solid companion to the many well-writt

textbooks on trauma management.This project represents many decades of collective clinical experience. We ha

assembled one of the largest collections of trauma images to help bring the reader the bedside of the patients. The acquisition and final assembly of this collection

images was a difficult process and they were acquired with the gracious cooperation of opatients. We regularly use these images in our clinical teaching and hope this atlas wsupplement other instructional resources in trauma management.

Demetrios Demetriades, MD, Ph

Edward J. Newton, M

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Acknowledgments

The authors greatly acknowledge the major contributions of Dr. Diku Mondavia,co-editor of the first edition of the atlas

Alexis DemetriadesScientific Illustrator, Illustrations and Image Processing

Robert S. Amaral, MA

Medical Illustrator, Illustrations

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1 Head InjuryDemetrios Demetriades and Leslie Kobayashi

Introduction

Head trauma is the most common cause of death andpermanent disability following trauma. Blunt head

injury is most commonly the result of motor vehiclecrashes, auto versus pedestrian collisions, or falls fromsignificant heights. Gunshot wounds cause the vast

majority of penetrating head injuries, although stabwounds and impalement injuries may also be seen.

Clinical Examination

Head injury is classified into mild, moderate, andsevere categories, depending on the patients GlasgowComa Scale (GCS) (see Table 1.1) at the time ofpresentation.

Mild head injury patients have a GCS of 1415.Typically these injuries include concussion or transient

loss of consciousness or neurologic function. Concussiondoes not result in any gross pathologic abnormalities ofthe brain, but subtle changes have been described using

electron microscopy. Although the neurologic examin-ation is usually normal, post-concussive neuropsychia-tric symptoms are common. These include amnesia ofthe event, headache, loss of concentration, dizziness,sleep disturbance, and a host of related symptoms. Thesesymptoms resolve within 2 weeks for the vast majority ofpatients but may persist for many months in a smallpercentage. Hard neurologic findings such as diplopia,motor weakness, pupillary abnormalities, and other cra-

nial nerve deficits are never due to post-concussivesyndrome and demand further investigation.

Moderate head injury (GCS 814) and severehead injury (GCS


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to light; the extraocular movements and other cra-nial nerve functions are assessed; motor and sensory

function is assessed for symmetry.Patients with increased intracranial pressure (ICP)

inevitably have some diminution in their typical levelof alertness. As ICP increases further, herniation of theuncus across the tentorium can occur, resultingin compression of the ipsilateral cerebral peduncle andipsilateral oculomotor nerve. Consequently, ipsilateralptosis, restricted extraocular movement, and pupillarydilation occur, along with contralateral motor posturing(decorticate, followed by decerebrate, and finally flaccidparalysis). Once this process begins, there is a very brief

interval for effecting a reversal by lowering ICP.

Investigations

All patients with GCS persistently


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General Management

The goal of cerebral resuscitation in the emergencydepartment (ED) is to prevent secondary injuries

to the brain, which are worsened by hypoxia,hypotension, seizures, hyperthermia, and hypercarbia.

Cerebral resuscitation and treatment are performed inthe context of overall resuscitation and are guided by

advanced trauma life support (ATLS) principles. Patientswith severe head injury tend to hypoventilate and are atrisk for aspiration of oral secretions. Consequently, secur-ing an airway and ensuring adequate ventilation are thehighest priorities. A brief neurologic examination should

be performed prior to using paralytic drugs for rapidsequence intubation (RSI) to secure the airway. Patients

with a GCS 8 require intubation, although patientswith a higher GCS may also need intubation.

Maintaining adequate cerebral perfusion pressure is

important in the face of increased ICP to preventsecondary ischemic injury. Consequently, measures

to maintain adequate systemic blood pressure areessential and include crystalloid infusion, blood trans-fusion, thoracotomy, laparotomy, and vasopressivemedications as indicated.

For patients with evidence of increased ICP orclinical signs of actual or impending transtentorial

herniation, immediate measures to decrease ICP areindicated. The patient should be adequately sedated,and analgesics should be used to control pain. Hyper-

ventilation to reduce pCO2to a level of 3235 mm Hgdecreases cerebral blood flow and thus decreasesintracranial blood volume, allowing a temporary

decrease in ICP. Osmotic diuresis with mannitol anduse of loop diuretics such as furosemide dehydrate alltissues including brain, again allowing more space for an

expanding hematoma and lowering ICP. These medica-tions must be used with extreme caution if at all inmultiply injured patients, as severe systemic hypoten-

sion may result; in these cases, consideration should begiven to the use of hypertonic saline. Hypertonic salinealso functions as an osmotic agent decreasing cerebraledema but without the diuretic effect often seen withmannitol. The neck should be cleared of any binding orrestricting devices or ties to improve venous drainage

from the head. Positioning the head at 30 degrees eleva-tion can decrease ICP once the spine has been cleared

radiographically. Placement of a ventriculostomy todrain cerebrospinal fluid (CSF) has been shown to beeffective not only in treating elevated ICP but also in

following the progress of the patients condition. Inrefractory cases barbiturate coma may be used todecrease cerebral metabolic demand. In extreme cases

a decompressive craniectomy or lobectomy may be cosidered. The patient should not be allowed to becomhyperthermic as this significantly increases cerebmetabolism and oxygen demand, the use of ice packTylenol or other antipyretic agents should be cosidered. Conversely the use of cerebral or systemic m

hypothermia has been shown experimentally improve outcome from severe head injury.

Definitive treatment for head injury depends on th

nature of the lesion. Closed skull fractures require nspecific treatment, but open fractures should be irgated, debrided, and closed. Depressed skull fracturrequire elevation of the fragment if it is depressed greatthan one bone width, and debridement if the wounis grossly contaminated. Basilar skull fractures usua

heal uneventfully, but patients with rhinorrhea otorrhea require careful follow-up to ensure that th

fistula closes. Most CSF leaks stop within 2 weeks, bpersistent leaks may require a formal dural closure. Moepidural hematomas (EDHs) require surgical evac

ation, although those that are24 weeks).

156 Abdominal Injury


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(c) Amniotic fluid embolization is a fairly rare buthighly lethal complication with a maternal mor-

tality of up to 80%. It is usually complicated byacute respiratory distress syndrome and dissemin-ated intravascular coagulopathy.

(d) Premature rupture of membranes.

(e) Fetal loss: Fetal mortality is high, even in fairlymoderate maternal injuries. Even in seeminglystable patients it is possible that there is fetalhypoperfusion and increased risk of fetal death.The mother may be compensating at the expenseof the fetus with uterine vasoconstriction. Pelvicfractures in pregnancy pose special problems and

the overall fetal mortality is about 35%.

(f) Uterine rupture occurs in about 1% of pregnawomen involved in motor vehicle injuries. is a life-threatening condition because of excesive bleeding and immediate laparotomy indicated.

Management

The trauma team should include the obstetrician ana neonatologist teams.

All pregnant patients should receive supplementoxygen, irrespective of SaO2,because the fetal hemglobin oxygen dissociation curve is to the left of th

A B

Figure 5.64 Placenta abruption is a common complication after trauma. Ultrasound is not very sensitive in the diagnosis. (A) C

scan is more reliable but it has the disadvantage of fetal irradiation. (B) Placenta abruption after a cesarian section.

A B C

Figure 5.65 (AB) Gunshot wound to the pregnant uterus. (C) A cesarian section was performed but the fetus did not survive



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A B

C

Figure 5.66 Penetrating abdominal trauma in advanced pregnancy. (A) The patient had signs of peritonitis. (B) A cesarean sectio

was performed during the exploratory laparotomy. (C) The baby survived after many weeks in neonatal ICU.

A B

Figure 5.67 (A) Stab wounds to the anterior abdominal wall of a pregnant patient. An emergency laparotomy and cesarean

section were performed. (B) The fetus also sustained a stab wound to the back and did not survive.

158 Abdominal Injury


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adult, resulting in fetal hypoxia despite normal mater-nal oxygenation.

In advanced pregnancy the patient or the spinalboard should be tilted about 20 degrees to the left inorder to reduce the compression of the inferior venacava by the uterus and improve venous return.

All Rhesus-negative patients should receive R(D)Immunoglobulin, in order to prevent isoimmunizationand erythroblastosis fetalis in future pregnancies.

In severe trauma, with nonviable fetus (24 weeks), if

maternal death occurs and the fetus is viable, in thpresence of major maternal complications (eclamps

DIC, amniotic fluid embolization), or during laparoomy if the exploration and management of materuinjuries is difficult due to the presence of the enlarguterus.

Perimortem Cesarean Section

This desperate procedure should be performed in casof maternal death or imminent death if the fetuspotentially viable (>24 weeks). The best results aachieved if the fetus is delivered within 5 minutes maternal death. Fetal survival with cesarean sectio1520 minutes after maternal death has bereported, although the incidence of hypoxic bradamage is high.



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6 Musculoskeletal InjuryEdward J. NewtonIntroduction

Orthopedic injuries are found in approximately 85% ofblunt trauma victims, and thus good knowledge in

their emergency care is important. Many injuries arealso acutely life-threatening or limb-threatening andneed to be evaluated in an expedited fashion. Despite

the importance of early treatment, the standard pri-mary survey evaluation with the advanced trauma lifesupport (ATLS) approach is necessary to detect otherinjuries that have a higher priority. During the primarysurvey, the only attention to musculoskeletal injury isacute hemorrhage control with direct pressure.


The physical exam is an integral component ofdetecting acute orthopedic injuries. The overlying

skin should be examined for contusions and lacer-ations. Lacerations need a more detailed evaluationfor neurovascular injury, tendon injury, foreignbodies, and proximity to fracture sites. Cool, pale skinmay indicate acute vascular insufficiency. Capillaryrefill and peripheral pulses are checked and compared

with the unaffected limb. In some cases Doppler ultra-sound may be required to detect poor pulses. Themuscle compartments are palpated for firmness that

may indicate an acute compartment syndrome. Gen-eral range of motion and areas of tenderness helpguide necessary radiographs. Careful peripheral nerve

exam is also important, as nerve injury may be part ofthe injury complex.

Investigations

1. Plain radiographs are necessary for most orthopedicinjuries. Fractures are usually evident on plain

radiographs, but occasionally the fracture is occurequiring further imaging guided by the clinic

exam. X-rays should view the affected bone in least two perpendicular planes and provide a fuview of the involved bone, including the joinabove and below. Depending on the spectrum injuries, full radiographic imaging may need

be delayed to stabilize the patient from lifthreatening injuries.2. Computed tomography (CT) scanning is useful

evaluating patients with continued pain and wi

normal plain radiographs, such as in acute hinjuries. CT scan provides much more detail

an identified injury and allows 3-D reconstructio3. Magnetic resonance imaging (MRI) is rare

needed to acutely evaluate musculoskeletal injur

It is useful in detecting occult fractures, as in hinjuries, and is also useful in delineating ligamenous and cartilaginous injury, such as may be see

with acute knee trauma. It has a prominent role spinal injuries.4. Bone scanning at 72 hours is occasionally used

follow up patients who may have occult fractures the scaphoid.

5. Doppler ultrasound, CT angiography or convetional arteriography, in conjunction with tanklebrachial index (ABI), are used to evaluapatients with possible vascular injury.

6. Intracompartment pressure can easily be measurwith portable equipment and can help guide thmanagement of patients with possible compa

ment syndrome.

General Management

Life-threatening injuries receive priority, and thmany orthopedic emergencies may receive moextensive evaluation and treatment in th

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postoperative phase. Some orthopedic injuriesrequire special mention as they are life-threatening

and need similar prioritization. Major pelvic frac-tures are associated with significant retroperitonealhemorrhage which is difficult to control. Liberalblood transfusions, expedited stabilization of thefracture, and emergency angiography with emboliza-tion may be necessary to hemodynamically stabilizethe patient. Major arterial injury with exsanguin-ation may occur with penetrating injury or by bluntforce with fracture or dislocation-induced vessellaceration. Depending on the involved vessel andthe clinical status of the patient, emergency opera-

tive therapy may be necessary to control bleeding.Acute crush syndrome causes traumatic rhabdomyo-lysis that will lead to acute renal failure if notpromptly managed with vigorous intravenous hydra-tion, diuretics, and alkalinization.

Open fractures and open joints are limb-threatening and need irrigation, tetanus immuniza-

tion, and parenteral antibiotics. Formal operativedebridement is done on an emergent basis. Traumaticamputations will need to be considered for emergencyreimplantation, and the amputated part appropriately

cooled and carefully cared for. Compartmentsyndrome may develop over hours, and thus high-riskinjuries need serial physical examinations and com-partment pressures evaluated. Dislocations needprompt reduction with deep sedation and neurovas-cular status checked before and after the reduction.Closed fractures need at least gross alignment withsplinting in the emergency department to decrease

bleeding and pain and prevent further displacementand injury of the adjacent neurovascular structures.Definitive closed or open reduction can be completed

once the patient has been stabilized from otherinjuries.

Common Mistakes and Pitfalls

1. Significant occult blood loss can occur wifractures of large bones such as the femur a

pelvis and can often account for acute hemorhagic shock. Anticipate large blood loss withese injuries while excluding other causes hemorrhage,

2. Compartment syndrome may insidiously develin the multitrauma patient, and thus repeat cliical examination is paramount for early diagnosof this condition. Pain out of proportion to thapparent injury is an early symptom and will ne

to be evaluated by assessing compartment presures. Segmental fractures in long bones such

the tibia are especially susceptible to compartmesyndrome.

3. Neurovascular injury complicates many fractur

and needs to be carefully sought. ABI, Dopplultrasound, or CT arteriography may be need

to delineate acute vascular injury.4. Occult fractures should be suspected in patienwith significant pain but with normal radiographFurther radiographs, CT scanning, MRI, or bo

scan may be necessary for fracture identification5. Pediatric radiographs are inherently more difficu

to interpret because of osseous growth plates anincomplete ossification. At times, comparisviews of the other extremity will be necessa

and occult fractures should be suspected in chdren with tenderness over the physis.

6. Long bone fractures should be splinted befo

transferring the patient to the radiology suiImmobilization of the fracture reduces pain anbleeding and prevents further damage to the ne

rovascular structures.

6.1 Classification of Fractures

Correct terminology is necessary and allows clear

communication when describing orthopedic injuries.Fractures are first described by anatomic location, andlong bones are usually divided in thirds describing thelocation of the injury. Open or compound fracturesrefer to fractures with a break in the overlying skin, incontrast to closed fractures which have normal skinintegrity.

The fracture line or pattern is then described an

follows the following common convention:

1. Transverse: fracture line perpendicular to the loaxis of the bone.

2. Oblique: fracture line oblique to the long axis the bone.

3. Spiral: fracture line curved in a spiral fashion.4. Comminuted: fracture with two or more pieces.

6.1 Classification of Fractures 1


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5. Segmental: fracture at two distinct levels.6. Torus: wrinkling or buckling of bone cortex seen in

pediatrics.7. Greenstick: incomplete fracture, seen in pediatrics.

Displacement refers to the degree of offset of the boneends relative to one another, and completely dis-placed fractures tend to be more unstable injuries.Displacement is described by outlining the position

of the distal bone relative to the proximal enA bayonet deformity refers to injuries with 100displacement and overriding of the bone ends wi

shortening of the affected extremity.Angulation refers to the angle between the long

tudinal axes of the main fracture segments. Fracturwith significant angulation generally require redution to maintain good function.

6.2 Open Fractures

Open or compound fractures are true orthopedic

emergencies. They are defined as fractures in contactwith the outside environment and thus require a break

in the skin covering the fracture site. The skin breakmay be large and obvious or a small puncture woundinjury, and thus determination if a fracture is open cansometimes be difficult.

The Gustilo classification is often used whendescribing open fractures:

Type I: Puncture wound


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open fractures of large bones require early operativeirrigation and debridement. Patients needing emer-gent operation for severe associated injuries can have

external fixation performed whereas stable patienare eligible for internal fixation. Mangled extremitimay require amputation.

6.3 Mangled Extremity

This condition is the result of severe crush trauma,

high-velocity missiles, or shotgun injuries. There is acombination of orthopedic trauma, extensive soft

tissue damage, and injury to the neurovascular struc-tures. The most immediate priority is to control bleed-ing, often by the use of tourniquets in the appropriate

cases. The initial clinical evaluation should include

assessment of the extent of skeletal and soft tiss

injury, the presence of peripheral pulse and skin pefusion, and motorsensory function. Patients wi

obvious nonsalvageable limbs should be transferrto the operating room for bleeding control and amptation. Investigations should be reserved only for cas

with possibly salvageable limbs. In these cases, pla

Figure 6.2 Open fracture of (A) mid-tibia, (B) elbow, and (C) knee.

A B

Figure 6.3 (A) Mangled right arm with severe crush injury. This patient accidentally placed his arm into an industrial mixer.

Amputation was required. (B) Mangled lower legs bilaterally, following a train accident. The patient required bilateral

amputations.

6.3 Mangled Extremity 1


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films should be obtained to determine the extent ofthe fractures. Color flow Doppler (CFD) studies, CTangiography, or conventional angiography may be

necessary to assess the vascular structures and planany vascular reconstruction.

The severity of the mangled extremity and theprediction of the need for amputation are commonlyassessed with the Mangled Extremity Severity Score

(MESS), which takes into account the extent of thskeletal/soft tissue injury, the presence and durationlimb ischemia, the presence of shock on admissioand the age of the patient. High scores are predictiof the need for amputation. Although this scori

system is a useful tool, it has significant limitatioand should not be the sole criterion in determininthe need for amputation or salvage operations.

6.4 Open Joint Injury

Open joint injuries are serious orthopedic emergen-cies with septic arthritis and osteomyelitis being

common complications. Detection may be straightfoward on physical exam or may be subtle, requirin

C D

E

Figure 6.3 (cont.) (C) Mangled leg following a motorcycle accident. There is extensive soft tissue loss with neurovascular

injury. The patient required amputation. (D) Mangled lower leg with fairly limited crushing and loss of skin and musc

The popliteal vessels were transected. Note the tourniquet above the knee which was placed to control severe bleeding.

The patient underwent successful reconstruction. (E) Near complete amputation of the leg following a motorcycle accidenThere is only a bridge of skin holding the leg in one piece.

164 Musculoskeletal Injury


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adjunctive testing. Any deep wound in proximity to ajoint should be considered as entering the joint.

Plain x-rays can show an associated fracture, air, ora foreign body within the joint but may be normal.Careful exploration under sterile conditions mayreveal a wound track directly penetrating the joint

capsule. In questionable cases, a saline or methylenblue arthrogram may provide the answer by reveali

dye leakage through the wound site. Emergency theapy includes parenteral antibiotic coverage and te

anus immunization. All major open joints requiformal exploration and irrigation.

6.5 Epiphyseal Injuries

In a growing child, the epiphyseal plate is a weakcartilaginous structure and is predisposed to injury.Injuries most often occur in the zone of hypertrophiccartilage cells, and the germinal cells are usually

undamaged; thus, fortunately growth is often naffected.

The most commonly used classification of epiphseal injuries is the SalterHarris classification. In th

A B

C D

Figure 6.4 (A) Open volar dislocation of the metacarpal joint. (B) Photograph (left) and radiograph (right) of an open joint an

fracture of the ankle. (C) Open joint and fracture of the ankle following a motorcycle accident. (D) Photograph of a methylen

blue arthrogram of the knee with leakage through the proximal wound signifying an open joint.

6.5 Epiphyseal Injuries 1


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classification, prognosis becomes progressively worsewith higher numerical order.

Type I: A very common slip through the zone ofprovisional calcification without fracture. Nogerminal layer is involved, and the fracture usu-ally heals without consequence. Comparisonradiographs are often necessary for diagnosis.

Type II: An epiphyseal plate slip with an associatedfracture through the metaphysis, forming a tri-angular fragment. This is a very common typeand forms three-quarters of all epiphyseal injur-ies. Prognosis is good.

Type III: An epiphyseal plate slip with a fracturethrough the epiphysis involving the articularsurface. This fracture involves the germinal

layer, and thus accurate reduction is necessa

but does not guarantee avoidance of growcomplications.

Type IV: Epiphyseal fracture involving both the plaand metaphysis. These fractures are complicateand significant growth disturbance can occunless good anatomic reduction is achieve

Operative intervention is often needed in thtype of fracture.Type V: Impaction injury in which the epiphyse

plate is destroyed. They are rare and difficult diagnose. Unfortunately, growth arrest is the ru

in this injury.

As with any pediatric injury consideration should bgiven to the possibility of nonaccidental trauma.

6.6 Torus and Greenstick Fractures

Pediatric bones are much less brittle than adult bones

and thus are less likely to have complete fracturesthrough the bone. A torus fracture is an incompletefracture with a small fold in the cortex. It is often seen

at the end of long bones. A greenstick fracture is

incomplete angulated fracture of a long bone reconized by a bowing appearance. These pediatric varants are common and can be easily missed.

A C

B

Figure 6.5 (A) Illustration of the Salter

Harris pediatric fracture classication. (B) Radiograph of Salter

Harris fracture involving tproximal phalanx of the thumb. (C) Radiograph of a juvenile Tillaux fracture. This is a SalterHarris III fracture of the ankle.



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6.7 Supracondylar Fracture

Distal humerus fractures that are proximal to theepicondyles are termed supracondylar fractures, and

most of these fractures occur in children aged 5years. In children, the ligaments and joint capsule a

Figure 6.6 Anteroposterior and late

radiograph of a distal radius torus

fracture.

6.7 Supracondylar Fracture 1


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stronger than the bone, and thus hyperextensioninjury often causes bone fracture while adults often

suffer a posterior dislocation of the elbow with asimilar mechanism.

Supracondylar fractures are of two common types:flexion and extension, with extension fractures the

overwhelming majority. These extension injuries areoften the result of a fall on an arm with the elbow fullyextended. On exam, the elbow will be swollen, oftenwith a joint effusion and with significant pain andtenderness. In addition, the olecranon will be moreprominent as it is attached to the posteriorly displaceddistal fragment. Careful neurovascular examination of

the arm is necessary as many of these fractures arecomplicated by brachial artery and median, radial,or ulnar nerve injury. In addition, compartment syn-drome can be seen with displaced fractures and needs

to be considered. If compartment syndrome continuunchecked, ischemic necrosis of muscle and nervcan result in Volkmans contracture which causpermanent dysfunction of the arm and hand.

Radiographically, these fractures are often detecton the lateral view of the elbow. Because many

these fractures are transverse they may not be readvisible on the anteroposterior view. In addition, up 25% of these are fractures of the greenstick variewith the posterior cortex remaining intact. The onabnormality seen may be a posterior fat pad sign or abnormal anterior humeral line. Supracondylar frature must be suspected in any child with acute elbotrauma, swelling, and pain, in spite of normal radioraphy. Most undisplaced fractures are treated non

peratively with casting, and most displaced fracturundergo percutaneous pinning.

6.8 Amputations

Amputations are devastating injuries and requireexpert knowledge in the care of the patient and the

amputated part. The area affected is important in thdecision to consider reimplantation. Lower extrem

BA

C D

Figure 6.7 (A) Photograph of a

swollen elbow of a child suffering a

supracondylar fracture. (B) radiograp

of the elbow shows displaced

extension supracondylar fracture. (C

Radiograph of a minimally displaced

transverse supracondylar fracture wi

the anterior humeral line passing

anterior to the capitellum. (D)

Illustration of the anterior humeralline. Normally this line intersects the

middle of the capitellum. With an

extension fracture, this line intersect

the anterior one-third of the

capitellum or passes entirely anterior



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reimplantation is rarely indicated, given the fre-quency of associated crush injury and the efficacy ofcurrent prostheses. In contrast, upper extremity ampu-

tations, especially involving the thumb, are oftenreimplanted, given the severe disability that occurs

with the loss of that single digit. Time elapsed sincethe injury is also an important consideration. Reim-plantation is less likely to be successful if the warm

ischemia (room temperature) time has been morethan 68 hours. If the part has been properly cooledand cared for, then this window of time may be

successfully extended to 1224 hours. In addition, cleasharp amputations are more likely to be successful thcrush injuries. In general, amputated parts should

considered as candidates for reimplantation, and evseverely crushed parts can be used for skin coverage.

The amputated part must be cared for properly maximize the chance of successful reimplantatioThe part should be handled minimally with no ant

septics. In addition, no debridement should occuThe part should be irrigated with normal saline anthen wrapped loosely in sterile soaked gauze. It shou

A B

DC

E F

Figure 6.8 (AB) Extremity amputations. (A) Photograph of a hand with thumb amputated secondary to a power saw injury;

(B) the amputated part in saline-soaked gauze. Reimplantation was performed. (CD) Amputated hand and multiple ngers

(secondary to the hand being caught in a gear mechanism). Reimplantation was performed. (E) Proximal tor. Reimplantation w

performed. (F) Amputated foot being cooled in ice water slurry.

6.8 Amputations 1


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then be placed in a watertight plastic bag and the bagplaced in an ice water mixture.

The patients stump should also be irrigated withnormal saline and direct pressure used to control any

bleeding. No antiseptics are used, but prophylactsystemic antibiotics and tetanus immunization shou

be administered.

6.9 Tendon Injury

Tendon lacerations are important injuries to detect,

and full examination of the hand will usually detectcomplete lacerations. Diagnosis of partial injuries ismore difficult, as tendon function is usually stillintact. A careful examination of the lacerationthrough the full range of motion is necessary, as theinjured area of tendon may retract out of the field ofview.

Flexor tendon repair in the hand is difficult andfraught with complications. Flexor tendon repair

should be performed by an experienced hand sur-geon, often in an operating room setting, although

extensor tendon injury over the hand and fingers canbe repaired in the emergency department. Prophy-lactic antibiotic, tetanus immunization, andsplinting are essential components of emergencymanagement.

6.10 Peripheral Vascular Injury

Most peripheral vascular injuries occur as a result ofacute penetrating trauma, with gunshot wounds beingmore damaging than stab wounds. Fortunately, blunttrauma rarely causes vascular injury except with

markedly displaced fractures and dislocations. Promidentification and repair is important, given the reltively short golden period of about 6 hours, aftwhich irreversible ischemic insult will occur.

Figure 6.9 This photograph illustrates the classic position o

extension in a patient with ngerexor injury.

Figure 6.10 (A) Photograph of a patient with a gunshot wound of the elbow with obvious demarcation of cyanosis

distally and absent distal pulses. Pulse oximetry is being used but is not sensitive for detecting vascular injury. (B) Gunshot



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Figure 6.11 (A) Gunshot wound to the arm with

bullet tract near the brachial vessels. CT

angiogram with 3-D reconstruction shows a

normal brachial artery. (B) Gunshot wound to t

thigh with a stable hematoma. CT angiogram

with 3-D reconstruction shows a normal

supercial artery. (CD) Patients with gunshot

wounds to the upper thigh. In both patients, Cangiography with 3-D reconstruction shows

transection and thrombosis of the supercial

femoral artery (arrow).

C D

Figure 6.10 (cont.) wound with an entry in the posterior thigh and a large groin hematoma anteriorly. Left foot is cool andpale (left). Operative view revealing associated femoral artery injury (right). (CD) Patients with gunshot wounds to the arm wi

large hematomas and diminished peripheral pulses. Both patients had injury to the brachial artery.

6.10 Peripheral Vascular Injury 1


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Physical examination is important for early diagno-sis, and most authors divide examination findings intohard and soft signs. Hard signs of vascular injury

include the following: pulsatile bleeding, unexplainedhypotension, absent peripheral pulse, expandinghematoma, palpable thrill, audible bruit, or evidence

of regional ischemia such as a pale, cool extremity.

In the presence of any of these signs, operative exploation is usually recommended.

Soft signs include moderate hematoma formatio

injury in proximity to major neurovascular tracperipheral nerve injury, and diminished but palpabpulses. To assist the evaluation of diminished pulse

the API (Doppler-determined arterial pressure in t

Figure 6.12 Gunshot wound to the knee. (A) The patient had diminished peripheral pulses and a bruit on auscultation.

(B) Angiography shows an arteriovenous stula.

Figure 6.11 (cont.)



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affected limb divided by the pressure in the unaffectedlimb) is often used to screen for injury. An index of

>0.9 generally excludes significant injury, and anindex of


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attention. CT angiography has become the investi-

gation of choice and has replaced conventional angi-ography in most cases. It is highly specific andsensitive, not invasive, and can be performed duringroutine CT scanning.

Besides acute limb loss, patients with these injuri

are also at risk for acute compartment syndromLate complications of missed injuries inclupseudoaneurysm formation, delayed thrombosarteriovenous fistula, and intermittent claudication

6.11 Peripheral Nerve Injury

Peripheral nerve injuries, though not life-threatening,

can cause significant long-term disability. Nerve injuriesare generally classified in the following three groups:

1. Neuropraxia: Mild transient nerve dysfunction

without gross anatomic disruption to the nerve,often secondary to contusion, local ischemia, orprolonged local pressure.

2. Axonotmesis: More extensive injury with interrup-tion of axons but with preservation of the neuralsheath. Complete loss of motor and sensory func-tion is seen distal to the site of injury. Spontaneousrecovery is possible and is dependent on the dis-

tance between the site of injury and the peripheralmuscles to be reinnervated.3. Neurotmesis: Complete severance of the nerve or

damage to the point where spontaneous regener-ation is impossible. This injury is often seenfollowing direct lacerations, severe contusions,

crushing or ischemic compressive injuries, elec-trical and thermal burns, and chemical injuries.

Physical examination can exclude peripheral ner

injury in a conscious, cooperative patient. Diagnosof peripheral nerve injury in a comatose or intoxcated patient is extremely difficult and is oftdelayed. Penetrating injury proximal to a nerve wneed careful examination and exploration. In adition, these injuries may have coexistent vascular

tendon injury to be excluded. Certain orthopedinjury complexes are more likely to harbor coexiste

nerve injuries and the following tables outlicommon injury patterns.

Completely severed nerves will need microsurgcal repair. In clean, sharp wounds, such as from

knife or glass, ideally this repair can be done earIf the injury is from a missile or crushing injury tparalysis is often due to neuropraxia and expectamanagement for 46 weeks is recommended befooperative repair is attempted. If the wound

grossly contaminated, then nerve repair should bdelayed.

Figure 6.15 Patient with complex

pelvic fractures and absent femoral

pulse. (A) Angiography shows

thrombosis of the left common iliac

artery (circle). (B) The thrombosis

was successfully managed with an

angiographically placed stent-graft

(circle).



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Common Peripheral Nerve Injuries

Radial Nerve1. Proximal Injury:

(a) Motor: Inability to extend the forearm, wrist,and fingers. Characteristic wrist drop.

(b) Sensory: Anesthesia over the dorsum of theforearm and the back of the hand at the base

of the thumb and first interosseous space.2. Distal Injury: No motor problems. Area of anesthe-sia over the base of the thumb, dorsally.

Median Nerve1. Proximal Injury:

(a) Motor: The patient cannot make a fist. Inabil-ity to flex the index and middle fingers, while

the ring and small fingers can be flexed (by thpart of the flexor profundus digitorum whiis innervated by the ulnar nerve). This is thbenediction or Popes hand. Loss of abdution, flexion, and a position of the thumb.

(b) Sensory: Anesthesia over the radial 3 finge

Ulnar Nerve

1. Proximal Injury:(a) Motor: Inability to abduct and adduct tfingers. If the patient tries to grip a ca

between the thumb and finger, this is onpossible by flexing the terminal phalanx

the thumb (Froments sign). The small fingis in abduction and slight flexion.

(b) Sensory: Anesthesia over the ulnar 1 finge

A B

Figure 6.16 Peripheral nerve injuries in the upper extremity. (A) Proximal radial nerve injury with the characteristic wrist drop(B) Ulnar nerve injury with the characteristic abduction and slight exion of the small nger.

Upper Extremity Patterns

Nerve Injury Upper Extremity Injury

Ulnar Elbow injury

Distal median Wrist dislocation

Median, anterior

interosseous

Supracondylar fracture

Musculocutaneous Anterior shoulder dislocation

Radial Distal humeral shaft fracture,

anterior dislocation of shoulder

Axillary Anterior shoulder dislocation,

proximal humeral fracture

Lower Extremity Patterns

Nerve Injury Lower Extremity Injury

Femoral Pubic rami fracture

Obturator Obturator ring fracture

Posterior tibial Knee dislocation

Supercial peroneal Fibular neck fracture, knee

dislocation

Deep peroneal Fibular neck fracture,

compartment syndrome

Sciatic Posterior hip dislocation

Superior and inferior gluteal Acetabular fracture

6.11 Peripheral Nerve Injury 1


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2. Distal Injury: Roughly the same problems as inproximal injuries, except that the flexor carpiulnaris and part of the flexor profundus digitorumretain their innervation.

Circumflex or Axillary NerveParalysis of the deltoid muscle results in inability toabduct the arm.

Musculocutaneous NerveInability to flex the forearm.

Sciatic Nerve1. Motor: Foot drop, weakness of the knee flexion.2. Sensory: Complete sensory loss below the knee,

except a narrow strip along the inner surface of theleg and foot, which gets innervation from the longsaphenous nerve.

Lateral Popliteal Nerve1. Motor: Paralysis of the extensor and perone

groups of muscles, resulting in foot drop.

2. Sensory: Anesthesia of the lateral leg, lower twthirds.

Medial Popliteal Nerve1. Motor: Paralysis of the calf muscles.

2. Sensory: Anesthesia of the sole.

Femoral Nerve1. Motor: Paralysis of the quadriceps and inability

extend the knee.2. Sensory: Anesthesia over a strip along the inn

surface of the leg and foot.

C

D

Figure 6.16 (cont.) (C) Operative view of a transected median nerve before (left) and after repair (right) (photograph courtesy

of Dr. Milan Stevanovic). (D) Operative view of a partially transected ulnar nerve before (left) and after repair (right)

(photograph courtesy of Dr. Milan Stevanovic).



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6.12 Metacarpal Fractures

Metacarpal fractures are commonly seen in the emer-gency department and are often secondary to directforce, such as a clenched fist injury. Fourth and fifthmetacarpal neck fractures of this nature are often

referred to as boxers fractures. Metacarpal fracturescan be classified in four types:

1. Head fracture: Rare injury.2. Neck fractures: Very common fracture with the

apex of the fracture being dorsal. Second and third

metacarpal fractures require accurate reduction forgood hand function, while the fourth and fifth

fractures can heal with angulation up to 35 and45 degrees respectively.

3. Shaft fractures: Can be transverse, oblique, spiror comminuted. Rotational deformities can occespecially with oblique and spiral fractures, anwill need identification and correction. This is be

evaluated clinically by having the patient flex thfingers into a fist. Rotational deformities will recognized by an abnormal lie of the affected digNormally the fingers of the flexed hand all poitoward the scaphoid bone at the wrist.

4. Base fractures: Uncommon fractures that are usally stable.

Most metacarpal fractures will have closed reductioalthough comminuted, spiral, and oblique fractur

may need operative fixation.

A B C

D

Figure 6.17 Metacarpal fractures. (A) Radiograph of a boxer's fracture of the fth metacarpal bone. (B) Radiograph of oblique

fractures of the metacarpal bones. (C) Radiograph of a displaced oblique fracture of the fourth metacarpal. (D) Photograph o

a rotational fracture of the right fth metacarpal. All ngertips should normally point toward the scaphoid.

6.12 Metacarpal Fractures 1


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First Metacarpal Fractures (Bennetts

and Rolandos Fractures)

First metacarpal fractures are classified as articular or,less commonly, nonarticular, with the latter beingeither transverse or oblique. Articular fractures arefurther described in two common patterns.

Bennetts fracture is an oblique fracture whichinvolves the carpometacarpal joint. It is usually dueto direct axial force on a partially flexed thumb, such

as in a fist-fight. The characteristic finding is a smalltriangular proximal fragment that remains anatomically

correct while the shaft is displaced in a dorsalrad

fashion by the pull of the abductor pollicis longus anthe abductor pollicis. Anatomic reduction is importanand these fractures are usually treated with percutaneopinning or even open reduction.

Rolandos fracture is a comminuted fracture at th

base of the first metacarpal. It is a relatively rafracture often caused by a similar mechanism toBennetts fracture. The treatment is controversand may vary from closed to open reductiodepending on the degree of comminution andisplacement.

6.13 Scaphoid Fractures

Fractures of the scaphoid bone are common andusually occur from a fall on an outstretched hand.Pain as well as tenderness is usually demonstratedin the anatomic snuffbox. Pain with axial forcealong the first metacarpal will also help identify

scaphoid injury.Scaphoid fractures are classified as proximal one-

third, middle third, and distal third fractures. The prox-

imal third does not have its own blood supply, and thusthese fractures are particularly at high risk for avascular

necrosis if treatment is delayed or improper. Plaradiographs are often diagnostic, but up to 20% m

present with normal radiographs initially. Patients wiscaphoid tenderness and normal radiographs are placin a thumb spica cast and will need a follow-up exam

A bone CT scan may be done in 3 days, or the patienmay have repeat radiographs in 10 days to detect occufractures. Nondisplaced scaphoid fractures are treatwith thumb spica immobilization, and displaced unstable fractures often need open reduction.

Figure 6.18 First metacarpal

fractures. (A) Radiograph of a

Bennett's fracture (arrow).

(B) Radiograph of a Rolando's

fracture (arrow).



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6.14 Scapholunate Dislocation

Scapholunate ligamentous injury is often secondaryto forced dorsiflexion of the wrist, as occurs in a fall onan outstretched hand. There is pain and tenderness on

the radial aspect of the wrist, just distal to Listerstubercle.

This injury is commonly missed, and radiographsshould be carefully examined for an abnormal gapbetween the scaphoid and lunate on the posteroanter-ior view. This joint space is normally less than 3 mm,and any widening of this space is representative ofa scapholunate ligamentous injury. This injury may

be treated with closed reduction and percutaneouspinning or may require open reduction. Missed sca-pholunate injuries often cause chronic arthritis and

pain or may cause ischemic necrosis of the lunate(Keinbocks disease).

6.15 Lunate and Perilunate Dislocation

Lunate and perilunate dislocation are relatively uncom-mon injuries that can easily be missed if the treatingphysicianis not familiar withnormal carpal relationships.

The injury often involves high energy, such as a fall or amotor vehicle crash,which causes extreme hyperexten-sion, ulnar deviation, and midcarpal dorsiflexion.

In the normal wrist, the lateral view reveals ththe distal radius, lunate, and capitate align themselvforming three Cs atop each other. This relationship

significantly altered with a lunate or perilunate dlocation, and thus a lateral radiograph usually reveathe injury pattern.

A

Figure 6.19 (A) Radiograph of a proximal one-thir

scaphoid fracture (arrow). This fracture is particula

at high risk for avascular necrosis if treatment is

delayed.

B

Figure 6.19 (cont.) (B) Scapholunate dislocation (arrow).

Note the widening of the joint space between the scaphoi

and the lunate.

6.15 Lunate and Perilunate Dislocation 1


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A lunate dislocation will demonstrate the lunatepushed off the distal radius in a spilled teacup signon the lateral view. On the anteroposterior view, thelunate will appear as a piece of pie sign. A perilu-nate dislocation demonstrates a capitate that isposterior or anterior to the lunate, while the lunate

maintains contact with the distal radius. The an

eroposterior view is less specific and shows obliterated joint space between the lunate and tcapitate. Treatment involves anatomical alignmewith closed reduction, though open reduction mbe necessary.

6.16 Wrist Fractures

1. Colles Fracture

A Colles fracture is the most common fracture ofthe wrist. It is a transverse fracture of the distalradius metaphysis, which is dorsally displaced andangulated. The fracture may also be intra-articularand can involve the ulnar styloid.

The usual mechanism is a fall on an outstretchedhand, and the wrist may demonstrate the classic dinnerfork deformity on exam. The treatment is usually closed

reduction, though more comminuted and displac

fractures will need open reduction and fixation.

2. Smith Fracture

A Smith fracture is often referred to as a reverColles fracture in which there is volar displacemeof the distal fracture fragment. It results from a fall oa flexed wrist or a direct blow to the dorsum of thwrist. Closed reduction will usually yield acceptab

A

B C D

Figure 6.20 (A) Illustration of types

lunate and perilunate dislocations. (

Anteroposterior x-ray of the wrist

showing a lunate dislocation with a

piece of pie lunate bone. (C) Late

radiograph view of the wrist with a

volar lunate dislocation. (D) Lateral

radiograph view of the wrist with a

dorsal perilunate dislocation.



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results although intra-articular Smith fractures oftenundergo open reduction.

3. Barton Fracture

Barton fracture is a distal radius fracture in whichthe carpus displaces volarly with the radial fragment.

A reverse Barton fracture is actually more commoin which the carpus displaces dorsally with fragment of the distal radius. Open reductiinternal fixation (ORIF) is usually performed fboth these fractures because both involve intr

articular fractures.

6.17 Forearm Fractures

When evaluating forearm fractures, it is important toremember that isolated fractures in this area are rare.Injuries may encompass two fractures at similar orseparate sites or may involve a single fracture with

ligamentous injury, with or without dislocation. Care-ful examination of the wrist and elbow joints is impera-

tive, as these are commonly involved sites. Some

common patterns are seen in forearm fractures and thknowledge of these injury patterns is important.

Both bones fractures (involving both the radius anulnar shafts) are often seen in children secondary

falls on an outstretched hand. They are only rareseen in adults and are then from high-energy mec

anisms or severe direct impact. In a child, radiograp

A

B

Figure 6.21 (A) Colles' fracture. Photograph of the classic dinner forkdeformity seen with

dorsal radius fractures (left). Lateral wrist radiograph of a Colles' fracture (right). (B) Radiograp

of a volar Barton fracture. The carpus displaces anteriorly with the distal radius fragment.

6.17 Forearm Fractures 1


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can reveal buckle or torus fractures, incomplete frac-tures, complete fractures, or a combination. Closed

reduction is often successful in children because smallamounts of residual angulation will resolve with boneremodeling. Complete fractures are more common inadults, and open reduction is often required.

The Monteggia fracture complex, first described in1814, is a proximal ulnar fracture with an associatedradial head dislocation. It is uncommon, representingabout 7% of all forearm fractures. The injury is causedby forced pronation of the forearm during a fall on anoutstretched hand. The radial nerve should be exam-ined as it is commonly injured. Radiographs easily

reveal the proximal ulnar fracture, and in these casesthe radial head should be carefully evaluated. In the

normal position, the radial head should align with thcapitellum when a line is drawn through the radial sha

Monteggia fractures are treated with open reduction.The Galeazzi fracture complex is a distal fracture

the radius with an associated dislocation or subluation of the distal radialulnar joint. The injuoccurs with a fall on an outstretched hand with wrin extension and the forearm forcibly pronated, with a direct blow to the dorsoradial aspect of thwrist. This injury is relatively rare and accounts fonly 7% of all forearm fractures. The anteroposteri

radiograph reveals a fracture of the radius at the juntion of the middle and distal thirds, and an increase

the joint space between the distal radius and ulna mbe seen. The lateral view will demonstrate dors

A B

DC

Figure 6.22 (A) Photograph and radiograph of a child with a both bones fracture. (B) Anteroposterior and lateral radiograp

of a Monteggia fracture. (C) Anteroposterior and lateral radiographs of a Galeazzi fracture. (D) Anteroposterior and lateral

radiographs of a nightstick fracture.



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angulation of the radial fracture, and the head of theulna will be displaced dorsally. Galeazzi fractures are

unstable and require operative fixation.Isolated ulnar shaft fractures or nightstick fractures

are relatively common. They occur as a result of directforce to the ulna, often happening when raising onesarm in natural defense to a blow from an object such

as a stick. In proximal ulnar fractures, the radial heshould be carefully examined to exclude the presen

of a Monteggia fracture. Associated injuries are rabut include compartment syndrome and vascuinjury. Most undisplaced fractures are treated wiplaster immobilization, while displaced fractur(>50% of width of ulna) may need open reduction

6.18 Elbow Dislocation

Elbow dislocations account for about 20% of all dis-locations and are the next most common dislocationafter the shoulder and fingers. They are usually theresult of a fall on an outstretched hand with armextended and abducted. Most elbow dislocations(>90%) are posterior, and the patient will present with

the elbow in 45 degrees of flexion, with a prominenceof the olecranon process posteriorly. The collateral

ligaments are torn, and careful neurovascular assement is important as brachial artery and median nerinjuries can complicate this injury.

Radiographs will reveal a dislocation. Most oftethe coronoid process will slip posteriorly, but occsionally a fracture of the process will be noted. Redu

tion is performed under conscious sedation countertraction with flexion of the elbow.

6.19 Radial Head Fracture

Radial head fractures are common injuries of the elbow

that usually occur with a fall on an outstretched hand orby direct trauma. The injury can result in damage to thearticular surface, depression of the radial head, or anangulated fracture of the radial head and neck. Often afracture is seen on radiographs, but they may reveal onlya fat pad sign indicative of an effusion and an occultfracture. Nondisplaced or minimally displaced fracturesare treated with a sling or posterior splint. Fractures that

are displaced more than 3 mm or involve more tha

one-third of the joint surface are usually treated opertively with the insertion of small screws. Comminut

fractures are treated conservatively, though the treament of severely comminuted and displaced fracturescontroversial and includes excision of fragments andor the radial head with or without the insertion Silastic implants. Early mobilization of the elbow important to reduce residual stiffness.

Figure 6.23 Posterior elbow dislocation: patient, plainlm, and 3-D reconstruction of patient with posterior elbow dislocation

6.19 Radial Head Fracture 1


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6.20 Humeral Fracture

Humeral shaft fractures are often the result of directblows to the arm, motor vehicle crashes, or minor fallsin the elderly. Physical exam reveals severe tendernesslocalized to the fracture area. Radial nerve injuriescomplicate up to 20% of humerus fractures, though

median and ulnar nerves are rarely injured.Plain radiographs are most often diagnostic, and

conservative treatment is used for the majority ofclosed injuries. The sugar-tong splint and hanging castare good techniques for immobilization. Open frac-tures, severely comminuted fractures, and fracturesthat are not adequately aligned by closed reductionare treated with open reduction.

Fractures of the humeral head most often occur inolder patients after minor falls. Associated rotator cufftears and fracturedislocation of the humeral head are

common complications. Initial management is with asling and swathe and the ultimate decision regarding

open or closed treatment is based on the patients age,

the number and displacement of fracture fragments,the quality of bone, and the presence of associatedinjuries.

A B

Figure 6.24 Radial head fractures. (A) Radiograph of a radial head fracture involving the articular surface. (B) Radiograph

of an impacted radial head fracture.

A B

Figure 6.25 Radiographs of humerus fractures: comminute

mid-shaft humerus fracture. (A) This fracture is at high risk f

radial nerve injury. (B) This injury is often associated with

brachial artery injury.



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6.21 Shoulder Dislocation

The shoulder is the most commonly dislocated joint.Shoulder dislocations can be classified as anterior,posterior, or inferior (luxatio erecta).

Anterior dislocations constitute>90% of all shoul-

der dislocations. They are usually the result of a fall onan outstretched hand with the arm abducted,extended, and externally rotated. On examination,the arm is held in slight abduction and external rota-tion. The humeral head is palpable anteriorly, and a

slight hollow is noticed in the shoulder laterally.Axillary nerve injury complicates shoulder dislocation

in up to 10% of cases.Standard radiography includes anteroposterior and

lateral views and either a transscapular Y view or anaxillary view. Radiographs may reveal a compressionfracture in the humeral head termed a HillSachs

deformity. In addition, a small anteroinferior glenoidrim fracture called a Bankart lesion may be seen.Recurrent dislocation is common especially with con-comitant rotator cuff tears.

Multiple techniques that use traction, leverage, or acombination can be used to reduce this injury, includ-

ing tractioncountertraction, external rotation, Stim-son technique, scapular rotation, and the Hippocratictechnique. Closed reduction is successful in the

majority of cases, though operative repair is used inirreducible cases, unstable joints, large glenoid rimfractures, >510 mm of displacement of avulsed

greater or lesser tuberosity fractures, intrathoracic dis-locations, and many posterior dislocations.

Posterior dislocations are rare injuries, about 5% of

all dislocations. They can be difficult to diagnose, andup to 50% are thought to be initially misdiagnosed.

The injury occurs with an axial load on an adductedinternally rotated and forward flexed arm, direct blowto the shoulder, or severe muscular contractions asfrom a seizure or electrical injury. The arm is usuallyinternally rotated on exam, and the patient is unable

to elevate the arm above 90 degrees. The anteropoterior radiograph may look nearly normal, and ththe transscapular Y view or the axillary view is necesary to exclude the diagnosis. There are four impor

ant radiographic findings associated with posterishoulder dislocation: the light bulb sign (rotatioof the trochanters into an anteroposterior plane leaing the humeral head with the appearance of a ligbulb), the deep sulcus sign (>6 mm distance betwethe humeral head and the glenoid rim), the trougsign (compression fracture of the humeral he

resulting in two vertical parallel lines), and the rior ellipse sign (loss of the usual elliptical overlap the humeral head and the glenoid rim). Not all sigare present in a single patient but the presence of anof these signs suggests a posterior dislocation. Redu

tion is accomplished by slow in-line traction, usuawith general anesthesia.

Inferior dislocation, also known as luxatio erecta,a very rare dislocation forming


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Luxatio Erecta Dislocation

Posterior Dislocation

Anterior Dislocation

AB

C

D

Figure 6.26 (A) Illustration of types of shoulder dislocations. (B) Anteroposterior radiograph of an anterior shoulder dislocatio

with a large HillSachs deformity. (C) Anteroposterior view of a posterior dislocation (left side) and axillary view of same patie

(right side). (D) Posterior dislocation showing loss of ellipse sign (left) and scapular-Y view showing the humeral head lying

posterior to the scapula (right). (E) Photograph of a patient with a luxatio erecta dislocation (left) and corresponding

radiograph (right).



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6.22 Clavicle Fracture

Clavicle fractures are common and can occur from a

direct blow to the clavicle or from a fall on outstretchedhand. Localized tenderness is found on examination,and radiography easily delineates the fracture. Compli-

cations are unusual but can include a host of seriousinjuries, including pneumothorax, subclavian vesselinjury, tracheal injury, pacemaker malfunction, andthoracic outlet syndrome with brachial plexus injury.

Most clavicle fractures can be treated conserv

tively with a sling or a figure-of-eight bandage. Opreduction is usually not necessary and is reserved fpatients with open fractures, irreducible fractures wi

soft tissue interposition, unstable fractures, associatacromioclavicular dislocation, associated brachplexus injury, or nonunion.

E

Figure 6.26 (cont.)

A

B

Figure 6.27 (A) Photograph of skin tenting seen with adisplaced clavicle fracture. (B) Clavicular fractures. Slightly

displaced medial clavicle fracture on plain radiography (left).

Mid-shaft clavicle fracture with signicant displacement. Thes

types of fracture are sometimes associated with subclavian

vascular injuries (right).

6.22 Clavicle Fracture 1


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6.23 Sternoclavicular Dislocation

The sternoclavicular joint is the articulation of themedial aspect of the clavicle and the manubrium

portion of the sternum. It is a ball and socket joint,and the dislocation may occur in any direction. The

injury is rare, accounting for 1.5% of all dislocations,and is usually caused by high-energy mechanisms suchas motor vehicle crashes or contact sports.

The injuries are classified as:

1. First degree: incomplete injury/stretching of thecapsule.

2. Second degree: mild subluxation.3. Third degree: complete dislocation.

The majority of these dislocations are anter(>90%). The less commonly seen posterior disloc

tion is associated with life-threatening tracheal compression and airway compromise, vascular injury, an

brachial plexus injury. First- and second-degree injuies are treated conservatively, but third-degree injuies may require reduction emergently if the airwaycompressed. Reduction is accomplished by havithe patient lie supine with the arm abducted whitraction is applied to the arm by an assistant. A towclamp may be used to lift the proximal clavicle anteorly if necessary. Reductions are unstable and oftneed surgical reinforcement.

6.24 Scapula Fracture

The scapula is integral to the normal function of theshoulder, and is rarely injured given its protection bythick surrounding musculature. Scapula fractures canbe classified as the following:

Body fracture

Acromion fracture Scapula neck fracture

Glenoid fracture

Coracoid fracture.

Body fractures are the most serious of these types andform about 1% of all fractures. Mechanisms of injuryinclude direct trauma, motor vehicle crashes, sports

injuries, falls, and crush injuries. Examination reve

tenderness over the body of the scapula. Associatinjuries are common, given the high energy require

to fracture the scapula, and they need to excluded. These injuries can include rib fractur

pneumothorax, hemothorax, pulmonary contusioclavicle fracture, subclavian vessel injury, spine frature, and skull fracture.

Anteroposterior and transscapular radiographviews are usually sufficient to delineate the injury. general, these fractures are managed conservativewith sling and swathe, though some authors pref

operative therapy.

A B

Figure 6.28 (A) Photograph of a woman with a right-sided anterior sternoclavicular dislocation. (B) The chest radiograph show

asymmetry of the clavicles with respect to the sternum, with the right sternoclavicular joint in an abnormal position (arrow).



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6.25 Pelvic Fractures

Pelvic fractures pose two major challenges for emer-gency physicians and surgeons. Firstly, there is a highincidence of associated intra-abdominal injuries

(about 28% of all severe pelvic fractures). The clinicalexamination may be difficult and hollow viscus injur-ies, which occur in about 13% of all severe fractures,

may be missed. Secondly, these fractures can bleedprofusely and the bleeding is difficult to control.

A common classification of the pelvic fractures is

based on the mechanism of injury and geography ofthe fracture, as follows:

Type A: Stable fractures. Isolated rami fractures, iliacwing fractures, or pubic symphysis diastasis lessthan 2.5 cm.

Type B: Partially unstable fractures (rotationa

unstable, vertically stable).B1: Pubic symphysis diastasis more than 2.5 cm an

widening of sacroiliac joints (open book fratures), caused by external hemipelvis rotatiforces.

B2: Pubic symphysis overriding, caused by internhemipelvis rotation forces.

Type C: Disruption of the sacroiliac joint due

vertical shear forces. Unstable fractures (rottionally and vertically), often associated wisevere bleeding.

C1: Unilateral.C2: Bilateral.

C3: Involving acetabulum.

A

B

Figure 6.29 Scapula fractures. (A) CT sc

of the chest showing a scapula fracture

(large arrow) and rib fractures (small

arrow) with a hemothorax (left). Scapu

view radiograph illustrating a mid-body

fracture with displacement (right).

(B) CT scan with 3-D reconstruction of

comminuted fracture of the scapula.

6.25 Pelvic Fractures 1


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ilium fracture with extensionto the sacroiliac joint

iliac wing fracture

sacroiliac joint

fracture-dislocation

transacral

acetabular

fracturespubic rami

fractures

pubic symphysis

separationischial fractures

Letournel Classification of Pelvic FracturesA B

C D

E

Figure 6.30 (A) Illustration of the different patterns of pelvic fractures. (B) Pelvic x-ray showing bilateral pubic and ischial ram

fractures resulting in a buttery fragment. This injury is often associated with signicant bleeding. (C) Pelvic x-ray showing

unstable Malgaigne fracture with widening of symphysis pubis, right acetabular fracture, left rami fracture, and left sacroiliac

joint disruption. This type of fracture is always associated with severe bleeding. (D) Pelvic x-ray shows severe pubic symphysis

diastasis. This is partially unstable and may be associated with signicant bleeding. Arrows show bilateral inferior rami fracture

(E) CT scan shows fracture of the sacral bone with severe displacement. It is usually associated with severe bleeding from

the presacral venous plexus or the iliac vessels.



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The abdominal clinical examination is often difficult,

because of the pain and abdominal wall hematoma

associated with the fracture. The patient should beevaluated for instability by gentle compression overboth iliac wings. This is a painful maneuver andshould not be repeated by other physicians for con-firmation or education. The clinical evaluation shouldinclude a rectal exam to rule out any rectal tears. Inaddition the prostate should be assessed for a high-

riding position, which is indicative of posterior rup-ture of the urethra. The meatus of the urethra shouldbe examined for any gross blood. A urethral catheter

should be inserted without using any force. In thepresence of any resistance the procedure should be

abandoned and a urethrogram should be performed.In the appropriate cases a vaginal examination shouldbe done to evaluate for vaginal tears.

Investigations

An anteroposterior portable pelvic x-ray is indicated

in order to assess the type and severity of the fractureand the suitability of applying a pelvic binder.

A trauma ultrasound (FAST) should be routinely

performed to rule out any significant intraperitonealbleeding. Retroperitoneal hematomas are usuallymissed by FAST. A diagnostic peritoneal aspir

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